Ground Ambulance and the No Surprises Act Gap

The No Surprises Act created strong federal protections against unexpected out-of-network bills — but it contains a notable gap: ground ambulance services are largely excluded. For many patients, a 911 ambulance ride that involves an out-of-network provider can still result in a large surprise bill, even after federal surprise billing rules took effect in 2022. Understanding why this gap exists, what limited protections may apply, and what practical steps to take is important for anyone navigating a ground ambulance bill.

For the full scope of what the No Surprises Act does cover, visit the No Surprises Act guide.

Why ground ambulance is a different category

When Congress drafted the No Surprises Act, ground ambulance presented a distinct set of complications. Ground ambulance services in the US are delivered by a patchwork of operators — private companies, county and municipal fire departments, hospital-based services, and volunteer emergency medical service organizations. Many are publicly funded, operate under different licensing frameworks than commercial healthcare providers, and are reimbursed through a complex mix of local taxes, user fees, and insurance payments.

Applying the same contractual balance billing rules that govern hospital-based physicians proved politically and administratively difficult. Congress chose to create a separate study process rather than impose immediate restrictions, resulting in the explicit exclusion of ground ambulance from the Act’s core provisions. Air ambulance — operated almost entirely by private companies — was treated differently and is covered by the No Surprises Act.

What the No Surprises Act does and does not cover for ambulance

Type of transport	No Surprises Act protection
Air ambulance (out-of-network)	Covered — patient cost-sharing limited to in-network amounts
Ground ambulance (out-of-network)	Not covered — federal balance billing protections do not apply
Ground ambulance (in-network)	Standard in-network cost-sharing applies through the provider contract
Non-emergency ground transport	Not covered by surprise billing rules in either case

The practical consequence is that a patient transported by an out-of-network ground ambulance in a medical emergency — often not by choice — may receive a bill for the full difference between what the ambulance company charged and what the insurer paid. This can range from a few hundred dollars to several thousand.

The federal Advisory Committee and its findings

The No Surprises Act required HHS, the Department of Labor, and the Department of the Treasury to jointly establish an Advisory Committee on Ground Ambulance and Patient Billing. The committee was tasked with studying:

• The prevalence and dollar amounts of ground ambulance balance billing
• Whether existing state laws provide adequate protections
• The financial sustainability of ground ambulance services and how billing rules might affect it
• Options for federal legislative or regulatory action

The Advisory Committee submitted its report to Congress, documenting that ground ambulance balance billing is a significant and widespread consumer problem. However, comprehensive federal legislation to close the gap had not been enacted as of the time this guide was reviewed. The issue remains before Congress, and the regulatory landscape may change. Check cms.gov/nosurprises for updates.

Documents and terms you’ll see

When dealing with a ground ambulance bill, you will encounter these terms on your EOB and in provider correspondence:

• Ground ambulance — emergency road-based medical transport; excluded from the No Surprises Act’s core balance billing protections, unlike air ambulance
• Balance billing — the practice of billing you for the gap between the provider’s charge and what the insurer paid; legal for out-of-network ground ambulance in most states
• Surprise bill — an unexpected bill from an out-of-network provider; the term is used colloquially for ground ambulance bills even though federal surprise billing law does not cover them
• No Surprises Act — the 2022 federal law covering most surprise bills; the ground ambulance exclusion is one of its most significant limitations for patients

What state laws may offer

In the absence of comprehensive federal protection, some states have enacted their own ground ambulance balance billing rules. State-level protections vary considerably:

• Several states prohibit ground ambulance services from balance billing patients who are covered by state-regulated insurance plans.
• Some states cap the patient’s out-of-pocket obligation at the in-network cost-sharing amount, even for out-of-network services.
• A few states require disclosure of costs before non-emergency transport.

However, these protections do not apply to self-insured employer plans, which are governed by federal ERISA law and preempt state insurance regulations. If your coverage is through a large employer’s self-insured plan, state ground ambulance billing rules may not protect you even if your state has enacted them.

Contact your state insurance commissioner’s office to ask specifically whether your state has ground ambulance balance billing protections, and whether those protections apply to your type of plan.

What to do if you receive a large ground ambulance bill

If you receive a balance bill from a ground ambulance service, take these steps before paying or accepting the amount as final:

1. Request an itemized bill. Confirm exactly what services were charged — base transport rate, mileage, oxygen, medications, and any other fees. Errors on ambulance bills, including mileage overcharges, are not uncommon.
2. Review your EOB. Confirm what your insurer paid and what it says you owe. If the ambulance company has any contract with your insurer, balance billing may be prohibited by that contract.
3. Ask whether the ambulance company is in-network. Call your insurer’s member services line. Some ambulance companies have negotiated rates with major insurers even without a formal network contract.
4. Ask the ambulance company about hardship programs. Many public and private ambulance services have charity care, hardship discount, or subscription programs. Ask the billing department directly whether any financial assistance is available.
5. Contact your state insurance commissioner. Ask whether your state has ground ambulance balance billing protections and whether they apply to your plan type.
6. Negotiate a lump-sum settlement or payment plan. If you owe the balance and cannot pay it in full, a lump-sum offer at a discount or a payment plan at zero interest is worth requesting. Document any agreement in writing before paying.
7. Check for subscription programs in your area. Some municipal ambulance services offer annual subscription programs that limit or eliminate balance bills for residents. These are worth knowing about before an emergency occurs.

The air versus ground distinction in practice

If you were transported by air — by helicopter or fixed-wing aircraft — you are in a different legal position. Air ambulance services are covered by the No Surprises Act. The air ambulance company cannot bill you for more than your in-network cost-sharing amount. If you receive a balance bill from an air ambulance provider, file a complaint with the federal No Surprises Help Desk at cms.gov/nosurprises.

The distinction matters because patients often do not know whether they were transported by a covered or uncovered service until the bill arrives. If you received emergency transport and are unsure whether federal protections apply, your insurer’s member services team can confirm whether the claim was processed as a covered or uncovered service under the No Surprises Act.